C 4 3 Form – Fill Out and Use This PDF

The C-4.3 form, or Doctor's Report of MMI/Permanent Partial Impairment, is a crucial document within the realm of workers' compensation. This form is specifically used when a doctor is providing an opinion on a patient’s Maximum Medical Improvement (MMI) and/or detailing any permanent partial impairment. It requires thorough completion and timely submission to the Workers' Compensation Board, the insurance carrier, and the patient's attorney, if applicable, to ensure the prompt delivery of necessary treatments and wage loss benefits. For the convenience of medical professionals, the C-4.3 form is also available for completion online. Click the button below to start filling out the form.

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C 4 3 Form PDF Details

In the complex landscape of workers' compensation, the C-4.3 form, otherwise known as the Doctor’s Report of MMI/Permanent Partial Impairment, plays a crucial role in defining the course of care and financial support for injured workers. This detailed document is primarily utilized by medical professionals to establish whether an individual has reached Maximum Medical Improvement (MMI) and/or if they are suffering from a permanent partial impairment as a consequence of their workplace injury or illness. These determinations are pivotal, not only in guiding the subsequent phases of medical treatment but also in influencing the compensatory provisions accessible to the patient. Furthermore, the C-4.3 form facilitates a structured communication channel between health care providers, the Workers' Compensation Board, insurance carriers, and legal representatives. The meticulous completion and timely submission of this form underscore its importance, as any negligence in this regard can significantly impede the patient’s receipt of necessary medical interventions, delay financial benefits, and necessitate legal testimony, thereby undermining the practitioner's standing with the Board. Moreover, the form’s design to accommodate additional narrative or documentation highlights its adaptability to the intricate and varied nature of work-related injuries and illnesses, emphasizing the personalized approach required in each case. Through sections dedicated to doctor and patient information, billing specifics, and detailed assessments of the patient's condition and functional capabilities, the C-4.3 form embodies a comprehensive tool for managing the multifaceted aspects of workers' compensation claims.

Question	Answer
Form Name	C 4 3 Form
Form Length	7 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 45 sec
Other names	4 3 form, mmi permanent, c4 3, c4 3 forms

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Doctor's Report	C-4.3
of MMI/Permanent Partial Impairment

Use this form: 1. When rendering an opinion on MMI and/or permanent partial impairment; or 2. In response to a request by the Workers' Compensation Board to render a decision on MMI and/or permanent partial impairment.

Please answer all questions completely, attaching extra pages if necessary, and submit promptly to the Board, the insurance carrier and to the patient's attorney or licensed representative, if he/she has one; if not, send a copy to the patient. Failure to do so may delay the payment of necessary treatment, prevent the timely payment of wage loss benefits to the patient, create the necessity for testimony, and jeopardize your Board authorization. You may also fill out this form online at www.wcb.ny.gov.

Date(s) of Examination:_______/_______/_______ WCB Case #:Claim Admin Claim Number:

A. Patient's Information

1. Name:				2. Date of Birth: _____/_____/_____ 3. SSN:			-	-
	Last	First	MI
4. Address (if changed from previous report) :
			Number and Street		City	State		Zip Code
5. Home phone #: (_____)_______________ 6. Date of injury/illness: _____/_____/_____					7. Patient's Account #:

B. Doctor's Information

1. Your name:

2. WCB Authorization #:

First

Last

WCB Rating Code:

4. Federal Tax ID #:

The Tax ID # is the (check one):

SSN

EIN

Office address:

Number and Street

City

State

Zip Code

Billing Group or Practice Name:

Billing address:

Number and Street

City

State

Zip Code

Office phone #: (______)_____________ 9. Billing phone #: (______)______________

10. Treating Provider's NPI #:

C. Billing Information

Employer's insurance carrier:

2. Carrier Code #: W

Insurance carrier's address:

Number and Street

City

State

Zip Code

4. Date of Exam:

5. Billing (CPT) Code:

Charge ($):

7. Zip Code:

C-4.3 (11-21) Page 1

C-4.3 11-21

Patient's Name:

Last

First

Date of injury/onset of illness:______/______/______

D. Maximum Medical Improvement

1. Has the patient reached Maximum Medical Improvement? Yes No If yes, provide the date patient reached MMI: _____/_____/_____

If No, describe why the patient has not reached MMI and the proposed treatment plan (attach additional documentation, if necessary).

E. Permanent Partial Impairment

1.Is there permanent partial impairment? Yes No

2.List the body parts and conditions you treated the patient for related to the date of injury listed in Section A, Question 6.

Complete Permanent Partial Disability, Attachment A and/or Attachment B, as indicated based on the patient's condition. Attachment A and/or Attachment B must be completed for each body part and/or condition which you treated the patient for on the date of injury listed in Section A, Question 6.

nFor a permanent partial impairment where schedule award (schedule loss of use) is appropriate, complete Attachment A, except for serious facial disfigurement, vision, or hearing loss.

Hearing Loss:

lOccupational Loss of Hearing - C-72.1 should be utilized, and/or

lTraumatic Hearing Loss - C4.3 with an attached narrative.

Vision Loss:

lAttending Ophthalmologist's Report (Form C-5), or

lC-4.3 with an attached narrative.

Serious Facial Disfigurement

lC-4.3 with an attached narrative.

nFor a non-schedule award (classification), complete Attachment B.

Sign below and submit to the Board only the pages of the form that apply to this report.

This form is signed under penalty of perjury.

Board Authorized Health Care Provider signature:

		/	/
Name	Signature	Specialty	Date
C-4.3 (11-21) Page 2		C-4.3 11-21

Patient's Name:				Date of injury/onset of illness:______/______/______
	Last	First	MI

Permanent Partial Disability - Attachment A

Schedule Loss of Use of Member

If the patient has a permanent partial impairment, complete Attachment A for all body parts and conditions for which a schedule award is appropriate (schedule loss of use). You must complete this attachment for all body parts and conditions for which you treated the patient for the date of injury listed in Section A, Question 6. Attach additional sheets if needed.

Body Part

Please include all the information in the bullet points below in the table on this page or attach a medical narrative with your report. The medical narrative should include the following information:

lAffected body part (include left or right side) and identify Guideline chapter (when special consideration exist).

lMeasured Active Range of Motion (ROM) (3 measurements for injured body part, and use the greatest ROM). If not, please explain why.

lMeasurement of contralateral body part ROM, or explain why inapplicable

lPreviously received scheduled losses of use to same body part(s), if known

lSpecial considerations

lLoading for Digits and Toes

C-4.3 11-21

Body Part/Measurement

Left

Right

Left

Right

Left

Right

Left

Right

Left

Right

Left

Right

Range of Motion

(3 measures)

Contralateral

Applicable Y/N

If No, please

explain below

Contralateral ROM

Special Considerations

(Chapter)

Impairment %

Details:

C-4.3A (11-21) Page 3

Patient's Name:

Last

First

Date of injury/onset of illness:______/______/______

Permanent Partial Disability - Attachment B

Non-Schedule Award (Classification)

1. Non-Schedule Permanent Partial Disability:

(Identify impairment class according to the latest Workers' Compensation Guidelines for Determining Impairment. Attach separate sheet for
additional body parts.)
Body Part:	Impairment Table:	Severity Ranking:
Body Part:	Impairment Table:	Severity Ranking:
Body Part:	Impairment Table:	Severity Ranking:

State the basis for the impairment classification (attach additional narrative, if necessary):

History:

Physical Findings:

Diagnostic Test Results:

2. Patient's Work Status:

At the pre-injury job

At other employment

Not working

3.Functional Capabilities/Exertion Abilities:

a. Please describe patient's residual functional capacities for any work at this time (not limited to the at-injury job activities):

Never

Occasionally

Frequently

Constantly

Lifting/carrying

lbs.

Pulling/pushing

lbs.

Sitting

Patient's Residual Functional Capacities

Standing

n Occasionally: can perform activity up to

1/3 of the time.

Walking

n Frequently: can perform activity from

Climbing

1/3 to 2/3 of the time.

Kneeling

n Constantly: can perform activity more

than 2/3 of the time.

Bending/stooping/squatting

Simple grasping

Fine manipulation

Reaching overhead

Reaching at/or below shoulder level

Driving a vehicle

Operating machinery

Temp extremes/high humidity

Environmental

Specify:

Psychiatric/neuro-behavioral (attach documentation describing functional limitations)

b. Please check the applicable category for the patient's exertional ability:

Very Heavy Work - Exerting in excess of 100 pounds of force occasionally, and/or in excess of 50 pounds of force frequently, and/or in excess of 20 pounds of force constantly to move objects. Physical demand requirements are in excess of those for Heavy Work.

Heavy Work - Exerting 50 to 100 pounds of force occasionally, and/or 25 to 50 pounds of force frequently, and/or 10 to 20 pounds of force constantly to move objects. Physical demand requirements are in excess of those for Medium Work.

Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects. Physical demand requirements are in excess of those for Light Work.

Light Work - Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Even though the weight lifted may only be a negligible amount, a job should be rated Light Work: (1) when it requires walking or standing to a significant degree; or (2) when it requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible. NOTE: The constant stress of maintaining a production rate pace, especially in an industrial setting, can be and is physically demanding of a worker even though the amount of force exerted is negligible.

Sedentary Work - Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

C-4.3B (11-21) Page 4

C-4.3 11-21

Patient's Name:

Last

First

Date of injury/onset of illness:______/______/______

Functional Capabilities/Exertion Abilities (continued):

c. Other medical considerations which arise from this work related injury (including the use of pain medication such as narcotics):

d. Could this patient perform his/her at-injury work activities with restrictions?		Yes	No
	If Yes, specify:

e. Could this patient perform any work activities with or without restrictions?		Yes	No
	Explain:

f. If patient is not working, could reasonable accommodations be made to enable the patient to perform work?				Yes	No
	If Yes, explain:

4. Has the patient had an injury/illness since the date of injury which impacts residual functional capacity?				Yes	No
	If Yes, explain. Attach additional sheets if necessary.

5. Would the patient benefit from vocational rehabilitation?		Yes	No
	If Yes, explain

C-4.3B (11-21) Page 5

C-4.3 11-21

How to Edit C 4 3 Form Online for Free

The ny c4 3 form filling out course of action is quick. Our software lets you use any PDF form.

Step 1: Look for the button "Get Form Here" on this website and press it.

Step 2: Now you will be on the file edit page. It's possible to add, customize, highlight, check, cross, include or delete fields or text.

Feel free to enter the next information to complete the ny c4 3 form PDF:

example of empty fields in mmi permanent

The system will need you to fill in the C Billing Information, Employers insurance carrier, Insurance carriers address, Date of Exam, Charge, Number and Street, Billing CPT Code, Zip Code, Carrier Code W, City, State, and Zip Code part.

part 2 to entering details in mmi permanent

Note the key information in C Page section.

step 3 to entering details in mmi permanent

The Patients Name, Last First MI, Date of injuryonset of illness, D Maximum Medical Improvement, Has the patient reached Maximum, Yes, If yes provide the date patient, If No describe why the patient has, E Permanent Partial Impairment, Is there permanent partial, Yes, and List the body parts and field is where both parties can put their rights and responsibilities.

End up by reviewing all these fields and preparing them accordingly: This form is signed under penalty, Name, Signature, Specialty, Date, and C Page.

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